Earl P. Steinberg

Surgical Rates and Operative Mortality for Open and Laparoscopic Cholecystectomy in Maryland

BACKGROUND Since 1989, laparoscopic cholecystectomy has been widely adopted as a treatment for gallstone disease. We analyzed the association between the introduction of this procedure and three variables: the rate at which cholecystectomy was performed in Maryland, the characteristics of patients undergoing cholecystectomy in routine clinical practice, and operative mortality. METHODS AND RESULTS We used 1985-1992 hospital-discharge data from all 54 acute care hospitals in Maryland, to identify open and laparoscopic cholecystectomies, characteristics of patients undergoing these procedures, and deaths occurring during hospitalizations in which these procedures were performed. The annual rate of cholecystectomy, adjusted for age, rose from 1.69 per 1000 state residents in 1987-1989 to 2.17 per 1000 residents in 1992, an increase of 28 percent (P < 0.001). As compared with patients undergoing open cholecystectomy, patients undergoing laparoscopic cholecystectomy tended to be younger, less likely to have acute cholecystitis or a common-duct stone, and more likely to be white and have private health insurance or belong to a health maintenance organization (P < 0.001). Although the operative mortality associated with laparoscopic cholecystectomy was less than that with open cholecystectomy (adjusted odds ratio, 0.22; 95 percent confidence interval, 0.13 to 0.37) and the overall mortality rate for all cholecystectomies declined from 0.84 percent in 1989 to 0.56 percent in 1992, there was no significant change in the total number of cholecystectomy-related operative deaths because of the increase in the cholecystectomy rate. CONCLUSIONS In Maryland, although the adoption of laparoscopic cholecystectomy has been accompanied by a 33 percent decrease in overall operative mortality per procedure, the total number of cholecystectomy-related deaths has not fallen because of a 28 percent increase in the total rate of cholecystectomy.

Hospital Readmissions in the Medicare Population

In order to examine the proportion of Medicare expenditures attributable to repeated admissions to the hospital, we assessed the frequency with which 270,266 randomly selected Medicare beneficiaries were readmitted after hospital discharge between 1974 and 1977. Twenty-two per cent of Medicare hospitalizations were followed by a readmission within 60 days of discharge. Medicare spent over

National Outcomes of Cataract Extraction: Increased Risk of Retinal Complications Associated with Nd.-YAG Laser Capsulotomy

2.5 billion per year (24 per cent of Medicare inpatient expenditures) on such readmissions between 1974 and 1977. Analogous expenditures in 1984 could approach

National Outcomes of Cataract Extraction: Retinal Detachment and Endophthalmids after Outpatient Cataract Surgery

8 billion. Even a small decrease in the readmission rate could result in substantial savings for the Medicare program. The recently enacted prospective-payment legislation, however, creates economic incentives that could increase readmission rates. Attempts by professional review organizations or others to develop hospital readmission profiles will need to control for patient and hospital characteristics that are correlated with the likelihood of readmission. Further study of such characteristics could help identify high-risk patient groups for whom increased outpatient supports might prove cost effective.

Predictors of Outcome in Patients Who Underwent Cataract Surgery

PURPOSE The authors studied 57,103 randomly selected Medicare beneficiaries who underwent extracapsular cataract extraction in 1986 or 1987 to determine the possible association between performance of neodymium (Nd):YAG laser capsulotomy and the risk of subsequent retinal break or detachment. METHODS Cases of cataract surgery were identified from Medicare claims submitted in 1986 and 1987 and were followed through the end of 1988. Episodes of cataract surgery, posterior capsulotomy, and retinal complications were ascertained based on procedure and diagnosis codes listed in physician bills and hospital discharge records. Lifetable and Coxs proportional hazards models were used to analyze the risk of retinal detachment or break in patients undergoing and not undergoing capsulotomy during the period of observation. RESULTS Of the 57,103 persons identified as having undergone extracapsular cataract extraction in 1986 or 1987, 13,709 subsequently underwent Nd:YAG laser capsulotomy between 1986 and 1988. A total of 337 persons had aphakic or pseudophakic retinal detachments between 1986 and 1988 and an additional 194 underwent repair of a retinal break. Proportional hazards modeling shows a 3.9-fold increase in the risk of retinal break or detachment among those who underwent capsulotomy (95% confidence interval: 2.89 to 5.25). Younger patient age, male sex, and white race also were associated with increased risk of retinal complications after extracapsular cataract extraction. CONCLUSION The authors conclude that there is a statistically significant increase in the risk of retinal detachment or break in those patients who undergo capsulotomy after cataract extraction. Therefore, capsulotomy should be deferred until the patients impairment caused by capsular opacification warrants the increased risk of retinal complications associated with performance of capsulotomy.

Variation in Cataract Surgery Practice and Clinical Outcomes

Background: A near-total shift to cataract extraction on an outpatient basis occurred as a result of an administrative ruling by the Health Care Financing Administration. No national study has been conducted to assess the possible effects of that decision on clinical outcomes of surgery. The authors compared the rates of retinal detachment (RD) repair and hospitalization for endophthalmitis after extracapsular cataract extraction (ECCE) (including phacoemulsification) in 1986 and 1987 with those following inpatient cataract extraction in 1984. Methods: Using the 5% random sample of Medicare beneficiaries, we analyzed the claims of all individuals 66 years of age or older who underwent ECCE by nuclear expression or phacoemulsification in 1986 and 1987. A total of 57,103 patients were identified and followed to the end of 1988. Cumulative probability of RD repair and hospitalization for endophthalmitis was calculated by standard lifetable methods. These findings were compared with the cumulative probability of the same complications in a cohort of 330,000 patients who underwent cataract extraction on an inpatient basis in 1984. Results: In the 1986-to-1987 cohort, the cumulative probability of RD within 3 years after cataract surgery was 0.81% and the cumulative probability of endophthalmitis within 1 year was 0.08%. The rate of RD is similar to that which we previously reported for 330,000 patients who underwent inpatient surgery in 1984, but the rate of endophthalmitis is significantly lower in the 1986-to-1987 outpatient cohort (0.08% versus 0.12%; z = 2.42; P = 0.01). Conclusions: The shift to outpatient cataract surgery was accompanied by no significant increase in the probability of RD repair and possibly a significant decrease in the rate of hospitalization for endophthalmitis.

Safety and Cost Effectiveness of High-Osmolality as Compared with Low-Osmolality Contrast Material in Patients Undergoing Cardiac Angiography

PURPOSE To identify preoperative patient characteristics associated with a lack of improvement on one or more measures 4 months after cataract surgery. METHODS The authors collected preoperative and 4-month postoperative information on 552 patients undergoing first-eye cataract surgery from the practices of 72 ophthalmologists in three cities. The principal outcomes assessed were (1) Snellen visual acuity, (2) a cataract-related symptom score (possible range: 0, 0 of 6 symptoms present or bothersome, to 18, all 6 symptoms very bothersome), and (3) a measure of functional impairment in patients with cataract--the VF-14 score (possible range: 0, inability to perform any of the applicable activities, to 100, no difficulty performing any of the applicable activities). Multiple logistic regression was used to assess the association between preoperative patient characteristics and failure to improve on one or more outcome measures. Multiple linear regression was used to estimate the adjusted rate of lack of improvement in one or more outcome measures for one group of patients compared with another. RESULTS Although 91 patients (16.5%) failed to improve on one or more of the outcome measures assessed, only 2 (0.4%) failed to improve on all three measures. The 91 patients who did not improve on at least one measure were approximately one sixth as likely to be satisfied with their vision postoperatively as the 461 patients who improved on all three outcome measures. Preoperative age of 75 years of age or older, VF-14 score of 90 or higher, cataract symptom score of 3 or lower, and ocular comorbidity (glaucoma, diabetic retinopathy, or age-related macular degeneration) were associated independently with increased likelihood of not improving on one or more measure (odds ratio: 3.57, 2.10, 3.29, and 2.16, respectively). The mean adjusted rate of failure to improve on at least one of the outcome measures ranged from 20.5% to 26.5% for patients with these preoperative characteristics compared with 8.8% to 13.8% for those patients without them. The preoperative level of Snellen visual acuity was not associated with the likelihood of not improving on one or more of the outcomes assessed. CONCLUSIONS The authors conclude that specific preoperative characteristics (age, comorbidity, cataract symptom score, and VF-14 score) are independent predictors of patient outcome after cataract surgery.

Geographic variation in utilization of cataract surgery

PURPOSE To examine associations between surgical technique, patient and surgeon characteristics, and clinical outcomes of cataract surgery. METHODS Seventy-five ophthalmologists were recruited from three cities based on a sampling scheme stratified by surgeon-reported annual volume of cataract surgery. Seven hundred seventy-two patients undergoing first eye cataract surgery were enrolled, with complete preoperative, perioperative, and 4-month postoperative clinical data on 717 patients (93%). RESULTS Sixty-five percent of surgery was performed by phacoemulsification and 35% by standard extracapsular (ECCE) techniques. Performance of ECCE was associated with the presence of ocular comorbidity and 21 or more years in practice of the surgeon. Performance of phacoemulsification was associated with annual volume of cataract surgery, wherein high-volume (201-399 patients annually) and very high-volume (> 400 patients annually) surgeons had 3.7 and 3.9 times the likelihood of performing phacoemulsification compared with moderate-volume (51-200 cases annually) surgeons. The rates of intraoperative, perioperative, and 4-month postoperative adverse events and the amount of improvement in visual acuity did not differ either by surgical technique or volume stratum. The reported occurrence of posterior capsular opacification within 4 months of surgery was increased in the presence of cortical opacification, one city, and patients operated on by either high- or very high-volume surgeons. CONCLUSIONS In this cohort, no difference in clinical outcomes, as measured by change in visual acuity or occurrence of postoperative adverse events (except for posterior capsular opacification), can be attributed to performance of phacoemulsification versus ECCE or to the reported annual volume of cataract surgery of the surgeon. Self-reported high and very high annual volume of cataract surgery is associated independently with performance of phacoemulsification and surgeons report of posterior capsular opacification at 4 months after cataract surgery.

Clinical indications for hysterectomy route: Patient characteristics or physician preference?☆☆☆

BACKGROUND AND METHODS Low-osmolality contrast agents produce fewer hemodynamic and electrophysiologic alterations during cardiac angiography, but they are 20 times more expensive than high-osmolality contrast agents. In a randomized, double-blind trial comparing a nonionic low-osmolality contrast agent (Omnipaque 350) with a high-osmolality agent that does not avidly bind calcium (Hypaque 76) in 505 patients undergoing cardiac angiography, we determined the incidence of minor, mild, moderate, and severe adverse reactions, identified risk factors for such reactions, and evaluated the cost effectiveness of various strategies for the use of contrast material. RESULTS The 253 patients who received a high-osmolality contrast agent were three times more likely to have a moderate adverse reaction (95 percent confidence interval for the relative risk, 1.6 to 5.5) but no more likely to have a severe reaction (95 percent confidence interval, 0.2 to 2.3) than the 252 patients who received a low-osmolality agent. All 10 severe reactions occurred in patients who were older than 60 years or had unstable angina. Patients with these characteristics were also 3.5 times more likely (95 percent confidence interval, 1.8 to 6.8) to have a moderate reaction (44 of 310 patients, or 14 percent) than those without either characteristic (8 of 195 patients, or 4 percent). We estimated that the incremental cost of each moderate reaction avoided would be

ACCURACY OF MEDICARE CLAIMS DATA FOR ESTIMATION OF CANCER INCIDENCE AND RESECTION RATES AMONG ELDERLY AMERICANS

1,698 with a strategy that involved giving a low-osmolality contrast agent only to patients who were over 60 years of age or had unstable angina, instead of giving a high-osmolality agent to all patients. The incremental cost per moderate reaction avoided by giving a low-osmolality contrast agent to all patients rather than only to those over 60 or with unstable angina would be